[Remote] Utilization Management (UM) Coordinator - remote opportunity

Note: The job is a remote job and is open to candidates in USA. Tivity Health is a leading provider of healthy life-changing solutions, and they are seeking a Utilization Management Coordinator to support clinical, management, and client activities within the UM Program. The role involves processing pre-authorizations, managing case assignments, and ensuring compliance with regulatory requirements.

Responsibilities

• Process documents through UM systems; CareRadius, CareAfiliate, RightFax, and Orion
• Track initial/concurrent service authorizations, denials, authorization gaps, and appeals status
• Manage and process case assignments for Clinical Peer Reviewers and Clinical Staff
• Process practitioner pre-authorization requests while adhering to administrative guidelines, policies and procedures
• Monitor turnaround time of tasks to meet regulatory requirements as well as specific state and federal requirements
• Maintain a high level of accuracy when processing letters in coordination with clinical peer reviewers. Coordinate letter QA with clinical peer reviewers to meet turnaround time requirements
• Maintain understanding of business rules and regulatory requirements pertaining to UM processes and operations
• Support departmental initiatives such as policy/procedure review, audit preparation, and work instruction updates
• Assist with monitoring client escalation mailboxes and responding to requests in a timely manner
• Practitioner outreach calls to meet regulatory requirements
• Conduct or support UM system testing (as needed)
• Self-assign and complete tasks as they appear in assigned buckets in CareRadius and Orion
• Assist in processing Grievances and Appeals (as needed)
• Other duties as assigned

Skills

• High school diploma/GED required
• One or more years' experience in a health care related field, preferably in managed care or utilization review
• Ability to read, analyze and interpret documents such as company policies, procedures, and operating instructions; ability to write routine correspondence
• Ability to solve practical problems and deal with variables. Ability to interpret various instructions furnished in written, oral, schedule, or electronic form. Ability to prioritize to meet deadlines and required turnaround times
• Ability to use computer software, including email, word processing and spreadsheets. Experience using CareRadius, CareAfiliate, RightFax, Orion is a plus
• Must exhibit strong interpersonal skills and professionalism. Strong verbal, telephonic and written communication skills are required. Ability to work under pressure; must have strong listening skills
• Ability to build relationships with internal/external customers. Ability to work with practitioners and office managers in an educational and in a problem-solving role. Ability to work remotely in a dedicated workspace with a door to protect company data and PHI. Must have high-speed internet
• Ability to support team goals and initiatives. Must be collaborative with team members while operating in a fast-paced regulatory environment
• Experience using CareRadius, CareAfiliate, RightFax, Orion is a plus

Benefits

• Competitive salary
• Company bonus potential
• Medical
• Dental
• Vision
• 401k with match
• Generous paid time off
• Free gym membership to over 13,000 fitness locations in the US
• Other great benefits

Company Overview

Company H1B Sponsorship